Advocates face lack of direction from feds on health care reform

By Jamey Dunn

Health care advocates are generally pleased with the benchmark benefits for individual and small group health plans that Gov. Pat Quinn’s administration chose to comply with the Affordable Care and Patient Protection Act. However, they worry about the lack of details coming from the federal government on how states should carry out those and other changes that came with federal health care reform.

The United States Department of Health and Human Services (HHS) gave states the task of choosing the basic level of benefits that plans for individuals and many small businesses will offer under the new law. “HHS decided to punt the ball to the states at least for 2014 and 2015,” said Lydia Mitts, a health policy analyst for Families USA, a health consumer advocate group based in Washington, D.C. In 2016, the federal government plans to revisit the benchmarks set by states. “But for now, it’s the states’ responsibility,” Mitts said. States picked existing plans to base the so-called essential benefits on.

Illinois had the option to choose among existing plans for federal and state workers, as well as several private options. Quinn’s advisory council opted for the Blue Cross Blue Shield's Blue Advantage plan. The council focused on finding a plan that included all of the state’s numerous insurance mandates. The one they chose does cover them all, but if they had picked one that did not, the state would have had to pay for any mandates that weren't included. Members also tried to find a balance between benefits and price. “One the big issues for the work group [was] balancing the cost of the coverage with the actual comprehensiveness of the care,” said Coleen Burns, special counsel for health policy for the Illinois Department of Insurance.

The plan will set the level of care covered in 10 benefits categories, such as emergency services and prescription drugs. Small group insurance providers will not have to offer plans with identical benefits to the Blue Cross Blue Shield plan, but they will have to offer benefits under those 10 categories that are equal to the benefits offered in the benchmark plan. “It will set a minimum that consumers will be guaranteed,” Mitts said.

But deciding which benefits are equal to those offered in the benchmark plan is a complicated task. Advocates say they need to be vigilant to ensure that other plans offer truly equal benefits. Burns said that the Department of Insurance will provide oversight and the federal government will provide actuarial analysis to ensure that benefits offered live up to the minimum requirements.

HHS still has to approve Illinois' choice of the Blue Cross Blue Shield plan. The department will accept  public comments, and Burns said HHS has not yet issued a deadline for when it will sign off on states’ choices. HHS is still working on many of the regulations for the plan, as well as on other areas of the Affordable Care Act, which states must implement by 2014. The uncertainty leaves many of those working to put the law into action on the state level unable to answer key questions until guidance comes down from the federal government. It also makes many advocates nervous.

“They didn’t really outline the clear chain of command and accountability,” Mitts said. “HHS is in the process of working on proposed regulation for this. Things might slip through the cracks, and people might find themselves in plans with coverage that doesn’t really meet their needs.”

Sara Moscato Howe, chief executive officer of the Illinois Alcoholism and Drug Dependence Association, agreed that things are uncertain. “Nothing is very clear in terms of how comprehensive or how robust the mental health or substance abuse coverage is.” She said that definitions of basic services, such as residential care for addiction or mental illness, differ across different plans, which could result in disparities in benefits. “Key definitions and terms need to be the same across the board.”

Brigid Leahy, director of legislative affairs for Illinois Planned Parenthood, said many advocates would have preferred the option to build a benchmark from the ground up instead of choosing from existing plans, but that wasn’t an alternative. “We feel given the parameters that were set under the Affordable Care Act ... given what we had to choose from, we were satisfied with the choice.”

Burns said most consumers who have small group or individual plans probably won’t notice much difference in their coverage “Most of the plans in the small group market covered all the 10 essential benefits. They just covered them at different levels,” she said. “It’ s unlikely that they are going to see a great difference in their benefits.” However, she noted that there are plans that do not cover some of the essential benefits, such as maternity care, and in 2014 they will be required to.